Medicaid

In a number of states, Republican lawmakers are making a stubborn stand against the expansion of Medicare coverage contained in the federal Affordable Care Act.

They laud themselves for having denied a tenet of Obamacare, sticking it to the president whose name is attached.

Trouble is, their main effect is to make life harder for constituents in their own states, not to mention throwing sand in the progress of health care reform.

Republicans in the Missouri General Assembly proudly tell us they will not expand Medicare this year in an effort to gain leverage over the federal government for vague and unlikely concessions next year. This is a fool's game. Even states whose leaders don't like the new law are signing up for Medicaid expansion because the consequences of doing otherwise are negative.

Those consequences are well known to Missourians: a loss of millions in federal health care assistance with associated damage to our state economy, and denial of health care help for hundreds of thousands of Missouri residents. Health care providers and economic development groups universally urge expansion. That General Assembly Republicans deny these traditional support groups is amazing. Either the partisans have imbibed the Kool-Aid by the gallon, or they believe hospitals, doctors and the Missouri Chamber of Commerce will have nowhere else to go with their political allegiance.

Opponents gripe about the requirement that Medicaid coverage must be extended to those at or below 138 percent of the federal poverty level without mentioning that cutoff is about $15,860 for an individual. Apparently they think this is plenty of income to allow people to buy their own insurance. More to the point, they don't buy the very idea of expanded affordable care, preferring to see hundreds of thousands without.

Obamacare is complicated because it represents a difficult change from a broken system, and to even get started it had to survive total unrelenting opposition from Republicans who fought over every detail of the new law, resulting in a number of compromises that make implementation hard. The ultimate goal is worth the struggle, but as long as the Republican Party is determined to be as obstructionist as possible, we will be in for destructive moves like our own legislative denial of Medicaid expansion.

I think most Americans support a national health care system that will provide affordable basic care for everyone. We can see proof of this thesis everywhere else in the developed world, where health care outcomes are better and costs are lower. Because this requires comprehensive federal oversight, opponents will parrot criticism of government per se, but they forget government is us and their knee-jerk opposition does nothing to improve health care. They should join in an all-out effort to develop the best system rather than try to stymie progress. But, alas, they have staked out such intransigent territory even the slightest relent will be unnecessarily hard.

The current Medicaid flap is possible because the U.S. Supreme Court allowed states to opt out of federal requirements for expansion. If the Affordable Care Act is a valid exercise of federal government prerogative, it's hard to figure why this particular carve-out was specified, but it helps show what a proper law will look like.

When the system is well developed, no unique Medicaid program will exist. Everyone will receive basic coverage under Medicaid regardless of income, poverty or age status. Coverage and contribution levels will be means-tested, as now is done partially. Basic coverage limits in the universal national health insurance policy will be determined by Congress and available through public or, at the option of providers, through private insurance. Individuals will be able to buy additional coverage with their own money.

Once this legal basic framework of coverage is established, we will continue with an eternal discussion about coverage limits and implications for funding. One salutary result will be the disappearance of employer group insurance, a perverse arrangement that enables coverage based on health characteristics of small particular groups rather than the large national population. The persistence of employer groups complicates reform progress and does nothing to improve potential individual coverage.

Meanwhile, Missouri Republicans deserve sharp rebuke for the harm they are doing. They are imposing pain on local employers and needy citizens and denying the state many millions in federal assistance that will go to other states. It's a GOP trifecta the party should not be proud of.

Add this to the litany of stances casting the GOP ever more firmly in a political corner, leaving a growing spectrum of the political landscape to others. Being against health care reform is a denial of the future.